Loss of Motor Evoked Potential in the Exposure Stage of Scoliosis Surgery in a Patient with Kyphoscoliosis.

Somatosensory-evoked potential and motor-evoked potential (MEP) are used during complex spinal surgeries to ensure the neurological integrity of the patient. Here, we report a case of a patient with type 3 thoracolumbar scoliosis whose surgery was stopped due to loss of signal in the neuromonitoring over the right lower limb in the exposure stage, before instrumentation and manipulation. The patient had right lower limb weakness and hence the surgery was abandoned. The same abnormality was present when we tried surgery for the second time. Surgery was aborted and the potentials recovered and the patient woke up without disability. In summary, this case illustrates that changes in MEPs can occur even at early stages in more vulnerable cases and is to be looked for to avoid disability.

Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations.

This study is conducted to review the literature systematically to determine most reliable outcome measures, important clinical and radiological variables affecting the prognosis in cervical spondylotic myelopathy patients. A literature search was performed for articles published during the last 10 years. As functional outcome measures we recommend to use modified Japanese Orthopaedic Association scale, Nurick's grade, and Myelopathy Disability Index. Three clinical variables that affect the outcomes are age, duration of symptoms, and severity of the myelopathy. Examination findings require more detailed study to validate their effect on the outcomes. The predictive variables affecting the outcomes are hand atrophy, leg spasticity, clonus, and Babinski's sign. Among the radiological variables, the curvature of the cervical spine is the most important predictor of prognosis. Patients with instability are expected to have a poor surgical outcome. Spinal cord compression ratio is a critical factor for prognosis. High signal intensity on T2-weighted magnetic resonance images is a negative predictor for prognosis. The most important predictors of outcome are preoperative severity and duration of symptoms. T2 hyperintensity and cord compression ratio can also predict outcomes. New radiological tests may give promising results in the future.

Impact of Comorbidities on Outcome Following Revision of Recurrent Single-Level Lumbar Disc Prolapse between Revision Microdiscectomy and Posterior Lumbar Interbody Fusion: A Single-Institutional Analysis.

OBJECTIVES: Reports exist in the literature on the relationship between comorbid conditions and recurrence of lumbar disc herniation. Meanwhile, documented evidence abound on microdiscectomy and posterior lumbar interbody fusion (PLIF) as techniques of managing recurrent disc prolapse. Some surgeons would choose to perform PLIF instead of microdiscectomy for a first time re-herniation, because of the possibility of higher chances of further recurrence as well as increased likelihood of spinal instability following treatment with microdiscectomy. In this study, the authors sought to determine whether PLIF is better than microdiscectomy for first-time recurrent single-level lumbar disc prolapse and to compare the impact of comorbidities on outcome following revision. PATIENTS AND METHODS: This was retrospective review of surgical treatment of patients with recurrent single-level disc prolapse with either microdiscectomy or PLIF at a tertiary health institution in India. RESULTS: A total of 26 patients were evaluated. There was no statistically significant correlation between the presence of comorbidity and outcome in terms of improvement of pain (P > 0.05 at 95% degree of confidence; Spearman's ρ =0.239). Patients who had PLIF were neither more nor less likely to have a better outcome compared to those who had microdiscectomy, though this finding was not statistically significant (odds ratio = 0.263; P = 0.284). CONCLUSION: There was no significant relationship between the presence of comorbidity and outcome following revision. Microdiscectomy did not prove to be a better option than PLIF for surgical management of recurrent single-level disc prolapse. A quality randomized controlled study would help to validate these findings.

Laminectomy Versus Laminoplasty in the Surgical Management of Long-Segment Intradural Spinal Tumors: Any Difference in Neurological Outcomes?

BACKGROUND: Previous comparative studies have shown that apart from lack of any significant difference in neurologic outcomes between laminoplasty and laminectomy following resection of intradural spinal tumours, spinal column issues such as postoperative deformities, malalignment, and adjacent level disease have also been clearly demonstrated to be quite similar for both techniques. However, there is no study yet that describes any difference in neurologic outcomes for long-segment intradural lesions as a rare subset of these lesions (in terms of number of spinal segments involved) following surgical management between these two techniques. MATERIALS AND METHODS: This is a retrospective review of surgical treatment with either laminectomy or laminoplasty done for patients with long-segment intradural tumors at a tertiary health-care institution in India. RESULTS: Out of over 167 patients surgically treated for intradural tumors during the study period, a total of 60 patients were included in the evaluation. The long-segment tumors were intramedullary in 22 (36.7%) patients and intradural-extramedullary in the remaining 38 (63.3%) patients. No patient in both cohorts had any revisional surgery after initial resection or any serious complications. The incidence of neurologic function remaining unchanged at the end of follow-up was similar between laminoplasty and laminectomy (12.5% vs. 11.1%). There was no significant correlation between the preoperative McCormick score and postoperative McCormick score (P > 0.05 at 95% degree of confidence; Spearman's rho = 0.028), suggesting that functional outcomes were not dependent on the initial neurologic status. Multivariate logistic regression analysis showed that : the two independent variables (Extent of surgery and Choice of procedure) were not significant predictors of the dependent variable (Functional outcome following surgery) (odds ratio = 3.836; p = 0.071). CONCLUSION: This retrospective evaluation demonstrates laminoplasty not to be more or less likely to have any better functional outcome or need for revision compared to laminectomy in the resection of long-segment intradural lesions. A quality randomized controlled study on a much larger scale will be required to validate this finding.

Single-stage deformity correction in children with neurogenic kyphoscoliosis: nuances and a proposal for risk stratification.

OBJECTIVE Neurogenic kyphoscoliosis in pediatric patients has varied causes and diverse management options. The most common management strategy is to stage the orthopedic and neurosurgical aspects of the correction at an interval of 3-6 months from each other. The aim of this study was to report the authors' experience with correction of deformity in children with associated neurological abnormalities requiring intervention as a single-stage surgical treatment. METHODS Of 591 pediatric patients with scoliosis treated at the Amrita Institute of Medical Sciences and Research Centre between January 2001 and January 2011, the authors identified all patients with neurogenic kyphoscoliosis who underwent deformity correction and a neurosurgical procedure in the same surgical session when they were younger than 15 years. Data regarding the demographic details, preoperative Cobb angle/kyphotic angle, surgical details, postoperative complications, cost of the procedure, and long-term neurological outcome were collected for each case and analyzed. Based on the results of this analysis, the authors propose a 2-category risk stratification system for the timing of deformity correction depending on the primary neurogenic etiology. RESULTS Ten cases involving patients with neurogenic kyphoscoliosis requiring both deformity correction and neurosurgical procedure met the criteria and were included in the analysis. All 10 patients were younger than 15 years; their mean age was 10.8 years. The average Cobb angle was 59.5°. Five patients underwent foramen magnum decompression, 5 patients underwent spinal cord detethering, and 1 patient had intraspinal intradural tumor excision. The mean estimated blood loss was 1177 ml (range 700-1550 ml), and the mean operative time was 4.4 hours (range 3-5.5 hours). There were no intraoperative complications. None of the patients had any new postoperative neurological deficits. The mean postoperative Cobb angle of the main thoracic curve was 12.6°. CONCLUSIONS Simultaneous deformity correction along with a definitive neurosurgical procedure in patients with neurogenic kyphoscoliosis can be performed without added morbidity and avoids both the added costs and the risk of complications associated with a second surgery. The risk stratification system proposed in this paper may serve as a guideline for case selection and help to optimize outcome.

The debate on most ideal technique for managing recurrent lumbar disc herniation: a short review.

BACKGROUND: Though different techniques have been successfully employed in the treatment of recurrent lumbar disc herniation, the one which should be considered most ideal has remained a controversy, particularly since there are currently no generally accepted guidelines for surgical care. OBJECTIVE: To review previous publications comparing the available operative options, with the aim of determining if any of the available interventions gives better outcomes compared to others. METHODS: A systematic literature review of previous publications comparing various techniques employed in the surgical treatment of recurrent disc herniation. RESULTS: All publications investigated in this review clearly demonstrated quite comparable outcomes, with no superiority of one method over the other. CONCLUSION: In view of the currently available data and evidence, minimally invasive techniques for revision of recurrent disc herniation do not really appear to be superior to the conventional open surgical approaches and vice-versa. We suggest the management strategy for surgical treatment of each case of recurrence to be simply based on the experience of the surgeon, the available facilities and equipment. Fusion should not be undertaken in all recurrences but should only be considered as an option for revision when spinal instability, spinal deformity or associated radiculopathy is present.

A short review on a complication of lumbar spine surgery: CSF leak.

Cerebrospinal fluid (CSF) leak is a common complication of surgery involving the lumbar spine. Over the past decades, there has been significant advancement in understanding the basis, management and techniques of treatment for post-operative CSF leak following lumbar spine surgery. In this article, we review previous work in the literature on the various factors and technical errors during or after lumbar spine surgery that may lead to this feared complication, the available options of management with focus on the various techniques employed, the outcomes and also to highlight on the current trends. We also discuss the presentation, factors contributing to its development, basic concepts and practical aspects of the management with emphasis on the different techniques of treatment. Different outcomes following various techniques of managing post-operative CSF leak after lumbar spine surgery have been well described in the literature. However, there is currently no most ideal technique among the available options. The choice of which technique to be applied in each case is dependent on each surgeon's cumulative experience as well as a clear understanding of the contributory underlying factors in each patient, the nature and site of the leak, the available facilities and equipment.

Massive spontaneous hemothorax, giant intrathoracic meningocele, and kyphoscoliosis in neurofibromatosis type 1.

Neurofibromatosis type 1 (NF-1) is a heterogeneous autosomal dominant disease with an incidence ranging from 1 in 2500 to 1 in 3000. Rare intrathoracic vascular disorders resulting in massive spontaneous hemothorax with fatal consequences may occur in these patients, so also are various types of skeletal dysplasia which may result in dramatic presentations, posing management challenges to the attending physicians. We report the case of a 43-year-old woman with NF-1 who developed spontaneous massive hemothorax and was discovered to have a concurrent giant intrathoracic meningocele and thoracic kyphoscoliosis with severe vertebral dysplastic changes. Surgical treatment via a right thoracotomy with primary repair of the meningocele and spinal fusion with fibula graft resulted in good outcome. This case represents an extreme manifestation of this otherwise indolent disease in clinical practice.

Temporal fossa arachnoid cyst presenting with bilateral subdural hematoma following trauma: two case reports.

INTRODUCTION: Intracranial arachnoid cysts are considered to be congenital malformations with a predilection for the temporal fossa. They are often asymptomatic but can sometimes be symptomatic due to enlargement or hemorrhage. There are multiple case reports of arachnoid cysts becoming symptomatic with hemorrhagic complications following head trauma. In such cases, the bleeding is often confined to the side ipsilateral to the arachnoid cyst. Occurrence of contralateral subdural hematomas in patients with temporal fossa arachnoid cysts has rarely been observed and is reported less frequently in the medical literature. CASE PRESENTATION: We report two cases of people (a 23-year-old man and a 41-year-old man) with temporal fossa arachnoid cysts complicated by a subdural hematoma following head injury. Both patients developed a subdural hematoma contralateral to the side of a temporal fossa arachnoid cyst. It is likely that lack of adequate intracranial cushioning in the presence of an intracranial arachnoid cyst may result in injury not only to ipsilateral but also to contralateral bridging veins, following head trauma. CONCLUSION: It is important to identify and report such rare complications with intracranial arachnoid cysts, so that asymptomatic patients with an intracranial arachnoid cyst can be counseled about such possibilities following head trauma.

Decompressive hemicraniectomy in malignant middle cerebral artery infarction: an analysis of long-term outcome and factors in patient selection.

OBJECT: Middle cerebral artery infarction often occurs at a younger age than other strokes and is associated with significant rates of mortality and morbidity. After a period of pessimism regarding decompressive hemicraniectomy in the management of acute stroke, the method has reemerged in the past decade. The present study was undertaken to assess the immediate and long-term outcome of this intervention and to help better define the selection criteria for surgery. METHODS: The authors conducted a nonrandomized prospective study using decompressive hemicraniectomy with duraplasty in patients at various stages of clinical deterioration due to a space-occupying middle cerebral artery infarct. Patients were assessed at 6 and 12 months postinfarction by using functional scales. Subjective reconsideration was assessed using a questionnaire. Twenty-six patients were included in the study. The mean age was 48.4 +/- 11.2 years, and the mean preoperative Glasgow Coma Scale score was 9.9 +/- 3.2. The median time from ictus to surgery was 54 hours (range 13-288 hours). The rate of survival at 1 year postsurgery was 73%. Among survivors, 33.3% were independent (Barthel Index [BI] > 95) and 55.6% were partially dependent (BI 60-95) at 1 year postsurgery, with 72% attaining the ability to walk independently by 1 year postsurgery. No patient remained in a vegetative state. The 1-year BI score was inversely related to patient age (r = -0.47, p = 0.048). CONCLUSIONS: Survival after decompressive hemicraniectomy was better than previously reported using medical management alone. A vegetative state was avoided and functional independence was possible, especially in younger patients. Increasing age was a statistically significant predictor of disability and long-term functional dependence.